Thursday, November 15, 2018

The Democrats' capture of the House of Representatives has saved the ACA's core programs and funding. Most fundamentally, Republicans have lost their chance to cut the trillion-plus dollars over ten years in federal healthcare spending that they tried to cut last year -- most of it in Medicaid. Instead, the ACA's expanded Medicaid eligibility may be available in seven more states by 2020 than in 2018. And the ACA marketplace's income-adjusted and relatively generous subsidies (compared to proposed Republican replacements) remain intact.

That said, early reports from Open Enrollment for 2019 suggest that various forms of Republican sabotage -- massive cuts to advertising and enrollment assistance, creation of a medically underwritten market in conjunction with repeal of the individual mandate -- may be taking their toll. Enrollment on HealthCare.gov, the federal exchange serving 39 states, was down about 13% in the first week (adjusted for a one day difference in days open) and 8% in week 2.

That could mean nothing, or it could mean a lot. Enrollment could catch up with last year's (which was down 5% in hc.gov states from 2017 and 9% from 2016), or fall further behind. Charles Gaba chalks the slow start up to election distraction -- in the media if not for the public at large -- although, weighing all factors pro and con, he'd previously predicted a 5% drop this year. Former HealthCare.gov chief marketing officer Joshua Peck is less sanguine:

it appears that the Trump administration’s relentless efforts to undermine the marketplaces and Open Enrollment is taking its toll. The effect of another year with minimal outreach, limited navigator funding plus new policies that drive up costs and drive down enrollment is greater than the sum of its parts. These actions impact awareness of both deadlines and the availability of affordable plans.

I would add a couple of notes to this. First, progressive analysts such as the Urban Institute predicted a more severe impact from the mandate repeal/noncompliant market expansion combo than did insurers pricing for 2019. Urban forecast that the mandate/short-term market combo would increase premiums by 18% in 45 states that do not prohibit or limit short-term plans (several states have since added limits), and that 2.6 million fewer people would have minimum essential coverage in 2019 than would have absent these changes. In fact premiums were nearly flat this year, mainly because it became apparent that insurers had massively overshot with last year's 34% average increase. Gaba calculates that premiums would have been about 8% lower than they are absent the mandate repeal/parallel market combo.

But while Urban may have miscalculated insurers' behavior in premium setting for 2019, they may have been closer to right in their estimate of consumers' reaction to mandate repeal and the short-term//AHP market. A friend who's a longtime individual market enrollee tells me that she's inundated with pitches for junk insurance, often billed as "Trumpcare" -- notwithstanding that she lives in Jersey, where short-term plans are banned.

Finally, this year's enrollment numbers may reflect more state divergence than in previous years. Six states ban short-term plans entirely; another 19 limit their duration to six months or less (see Louise Norris for a complete list of state limitations). The twelve state exchanges have longer enrollment periods than HealthCare.gov's and have for the most part maintained their outreach efforts. New Jersey, Washington D.C. and Vermont have passed state-based individual mandates (Vermont's to take effect in 2020). And in Jersey, the Murphy administration has instructed all state agencies to promote enrollment.and launched an online GetCoveredNJ with various resources.

Finally, Minnesota and Washington, which run state-based exchanges, have both announced enrollment totals ahead of last year's -- though as Gaba points out, those numbers may be an artifact of early tallying of auto-enrollment.

It's early days, but the trend is worrisome. Those who'd like to help get word out via social media can tap into the online resources at GetAmericaCovered, or GetCoveredNJ, or other similar state-based efforts.

About Me

I'm a freelance writer focused mainly on the unfolding drama of Affordable Care Act implementation and health reform more generally.
I have a Ph.D. in medieval English literature and a propensity to parse the rhetoric and logic of our political leaders as well as that of media pundits and scholars who jump into the national debate. I wrote a dissertation on the remarkably humane and subtle medieval English anchorite Julian of Norwich, a mystic nun whose knack of squaring circles and framing paradoxes reminds me a little of our current president. A sampling of that work (mind the google gaps) is here: http://bit.ly/OzwsrR